In Treatment, Season 4, Episodes 3 and 4

Episode 3, Laila, and Episode 4, Brooke and Rita, aired four days ago. Usually I like to post about each episode within a day of its airing but this time I have just had a hard time finding what stood out for me. So read this with my ambivalence in mind.

Laila —

Laila is brought to her first session by her grandmother who seems to think that 2 or 3 sessions should be enough. Laila, she says, is “choosing to be gay” and grandmother wants her prepared for what she faces in college.

I confess it has been years since I worked with a teenager — once my own kids were teens, I just didn’t want to deal with more teen issues. And I confess that Laila reminds me why. She is defensive, provocative, sarcastic, often hostile. Brooke manages all of this pretty well, even though none of her efforts gets Laila to speak of herself other than with labels. She gets Laila to move out of the usual physical set up of sitting opposite each other and move to a table where they eat Easter candy. But Laila stays guarded.

We don’t learn a whole lot about Laila in this episode. We know she says she is gay. She claims to be a sex addict. She’s the only child of what she describes as a workaholic. Her grandmother has taken the place of her mother — but what happened to her?

Brooke’s effort to reach Laila and her recognition that she has to earn her trust are spot on but it remains to be seen if Laila will really engage in therapy. It is the relationship between therapist and patient which is the vehicle for the work of therapy and Laila is pretty armored.

Brooke and Rita

Rita is Brooke’s friend who shows up after  having been away for a while. We learn that Brooke’s still mourning her recently deceased father, and her toxic ex Adam  is slowly but surely easing his way back into her life. And that Rita is apparently her AA sponsor of many years. So here is the dual relationship again — the friend who is also her sponsor.

This was difficult for me. I was critical of Paul in the first seasons for having a dual relationship with Gina, for the blurring of lines between friendship and supervision. But there was at least a nod given to the need for a professional component in that relationship, a component that is missing this season. All of us therapists have issues in our own lives. Part of our task is to stay on top of them and not use work with patients to deal with them. Supervision and personal therapy are the best checks on what we call countertransference. Given Brooke’s loss of her father and what seems to be complications in her relationship with her boyfriend, to say nothing of the stresses and strains she, like everyone, is subject to during the last year of COVID restrictions. 

Rita does ask Brooke some pointed questions, but the fact remains they are friends and that is the relationship, not a therapeutic one. Which is not to say that friends cannot be immensely helpful but to me, this is a case where it would help a lot if Brooke availed herself of supervision and/or therapy.

So we’ll see how this unfolds. 

In Treatment, Season 4, Colin 1

Brooke’s second patient, Colin, is a court referral, referred for four sessions of mandated therapy. He was a tech executive who fell afoul of the law and went to prison for financial crimes. The woman with him, a parole officer I suspect, tells Brooke he must attend the sessions and that the basis for the referral is his anger issues. Brooke sees Colin face to face in her home office.

Charming at first, there’s a definite darkness underneath. He complains about the burden of being a privileged white man, knowingly provoking Brooke. Colin tells Brooke he has been therapy before, is glad to be there and glad to be out of prison. He says he “fucked up” his life. His accounting of himself is liberally laced with swearing, which he checks to see if she minds. He denies any history of violence, says he is a pacifist raised by hippies.

Colin looks around a lot and evades Brooke’s questions. He asks about her husband getting her to say she is not married. She says he is her first pro bono patient. He says he wants to talk about her, get to know her. Brooke tells him she grew up in the neighborhood they are in, that her father designed some of the houses in the area.

There is throughout an underlying tension. Colin seems used to being able to charm his way into getting what he wants. Brooke asks questions he does not want to answer. He tells her had a bad day in prison and reached his breaking point — she reminds him that in fact he was put into seclusion. He says he ruined his life.

At every turn, Colin resists giving details about himself and his history. He tried to provoke her but she resists. She confronts his downplaying and evasion. Colin is impressed and says, “You’re good. I hadn’t anticipated that.” But he is angry at her confrontations and is defensive. He claims he gets “pummeled” every time he opens up. “You want me to be safe”, he says, “but I am not safe.” This leads to mini-debate about words and a brief outburst by Colin. Clearly his charm is not working as he expected.

Brooke asks how it has been since he got out of prison. He tells her it’s okay but that people don’t want to be around him. Then he says “I fucked a lot of therapists. How about you? Have you fucked a patient?” and shits on his former therapists. Brooke wonders if he is up to the work of therapy. He apologizes and attributes his behavior to stress. Lots and lots of words but not much meaning.

Colin leaves. Brooke gets up and gets herself a drink.

 Colin is a tough patient. I wonder why Brooke is willing to take him on under the four sessions mandate because it is very doubtful that anything meaningful can be accomplished in that time. No doubt there is a lot to mine in Colin’s history and it likely would take a fairly long time to get him to settle down and actually engage with Brooke in their shared work.

Colin masks his rage and hostility beneath a thin veneer of charm. He talks a lot but much of what he says seems aimed at getting a rise out of Brooke. She skillfully parries his attempts to goad her. My guess is that it is a bit of an exhausting hour — witness her need for a drink after he leaves. And what is that about? Why alcohol? 

What do you think about Colin? About Brooke’s response to him? Does anything surprise you?

In Treatment, Season 4, Eladio 1

And so we begin Season 4 of In Treatment. This is a show which does a reasonably good job portraying psychotherapy. Each session is condensed into 30 minutes, shorter than actual sessions but manages to convey something close to what actual therapy is like, as close, probably, as television can come without turning to a reality show format.

Let’s start with what is different from the get-go in this season. The show is set now in Los Angeles rather than Brooklyn. The colors of Brooke Taylor’s home office reflect a brighter California palette rather than the more somber browns and leather of Paul’s Brooklyn office. Like Paul, Brooke has her office in her home. For the past nearly 15 months nearly all therapists have been working with patients from their homes via video connection or telephone. In the first session, we see Brooke work as most of us have been, in the virtual space of video connection. This season we see in both therapist and patients a heightened sense of the need for diversity, which is a change from the first 3 seasons. We see from Brooke’s email box and photos that she has some kind of relationship, perhaps as a protege, with Paul Weston, the therapist from the earlier iteration of the show.

Our Sunday patients are Eladio and Colin. We learn from Episode 1 that Eladio is a home health aide employed by a wealthy family to care for their son; the empolyer is paying for Eladio to see Brooke. The season opens with Brooke receiving a phone call late at night. She declines the call but the caller immediately calls again and we see it is Eladio. He tells her he didn’t expect her to answer then tells her a dream. 

Next we see Eladio is video session with Brooke. Brooke apologizes for answering the phone the previous night. In what follows we learn that Eladio has not spoken with his mother for 4 or 5 months, that she had COVID and that she refused his help. And we learn he is an only child though his mother told him there was a stillbirth before he was born.

Brooke tells him he can call her in emergencies. Eladio reacts to this, telling her not to do that, to do what feels to him like rapping on the knuckles—this suggests his desire for unlimited access to Brooke. She tells him it is up to her to set boundaries. He rather quickly tells her he wants a referral for medication because he isn’t sleeping. She says she needs to know him better before she can feel comfortable making such a referral and she quotes Jung —“There is no coming to consciousness without pain.” She lets him know she is not casual about meds, that this work is not fast and that hers is not a results oriented practice.

Eladio then tells her he was diagnosed Bipolar I in college and is on lithium which he takes when he can afford to buy it. His employer does not know about his diagnosis. That he used to work with old people that he would become attached to then they would die. — that is when his sleep problems began, he says. That he fell in love with an addict who abruptly cut him off. Brooke tells him it sounds like he is haunted. Then Eladio asks her if she is going to take care of him, be his family. The session ends abruptly when his charge needs assistance.

So what do I notice?

First, like Gabriel Byrne, Uzo Aduba is riveting in the part. She is beautifully dressed in bright colors very like the furnishings in her home office. My sense though is that the orange chairs in the office are not especially comfortable and she shifts about in her seat as if that were the case. The chairs look great, but for a day’s worth of work? Maybe not so good.

Setting boundaries with Eladio right from the beginning is important. That after having seen her only twice he calls her late at night is an indicator for her that he needs boundaries. A friend of mine and I spoke recently about late night calls and that we have rarely if ever had any while in private practice. So Eladio’s call is at least unusual. And we see as the session progresses that he is hungry for a mother, being somewhat estranged from his own and having experienced so many losses. Brooke’s observation that Eladio is haunted — by the deaths of his never known sister and the patients he cared for and the disappearance of his addict lover — stands out and leads Eladio to express his need for family and care. 

What do we learn about Brooke from this first session? Her father recently died, so we know she is grieving. It looks like she lives alone. So we know that she, like most of us, is dealing with her own pain and issues as she works with her patients. Surely Eladio’s losses bring her own to her mind, as happens again and again in depth psychotherapy.

Now a quibble. In looking for the whole of the Jung quote, I learned that Jung never said: “There is no coming to consciousness without pain.” 

What he said in two separate and unrelated statements was:

“Seldom, or perhaps never, does a marriage develop into an individual relationship smoothly and without crises; there is no coming to consciousness without pain”. ~Carl Jung, Contributions to Analytical Psychology

and 

“People will do anything, no matter how absurd, in order to avoid facing their own souls. One does not become enlightened by imagining figures of light, but by making the darkness conscious.” ~Carl Jung, Psychology and Alchemy

With that small correction, still I am delighted that Jung is mentioned. And this sets Brooke within the field of depth psychotherapy and explains her statement to Eladio that hers is not a “results oriented practice.” It doesn’t mean that patients do not change but that particular results are not the goal.

What are your thoughts? Comments? Impressions?

Later today, our second patient, Colin.

Attention Fans of In Treatment!

Ten years ago, HBO’s In Treatment ended its third season with no prospects in sight for renewal. I had blogged every one of the episodes as they were broadcast, a big undertaking for what was then a relatively new blog. I loved the series and see it as the best fictional representation of therapy that I have seen. The liberties taken for the sake of drama and the way the pace of therapy was made to fit the show did not bother me for it was the issues it raised and the interactions between therapist and patient it showed that struck me. And it was a good opportunity to discuss ways the the therapist, as portrayed by Gabriel Byrne, deviated from and/or stayed with the boundaries of therapy. So when it ended, I was very disappointed. I had not only written a lot about the show, but had also used it to teach three courses in my local Senior College.

Imagine my delight when HBO announced a little while ago that it was bringing one of my all time favorite shows back for a new season. And now the debut of Season 4 is almost upon us – starting tomorrow, Sunday May 23.

We will see a new therapist, played by Uzo Aduba, a black woman. And it is set in Los Angeles rather than New York. For an overview of the coming season, check out this article from the NY Times. And I will be posting my comments on each episode starting Monday morning. 

In order to be good, I have to feel bad…

 Anyone who looks at me can see that I am fat, yet even calling myself fat and not being embarrassed or ashamed of that simple fact is less ordinary than we might think. Stigma is attached to being fat. Everywhere every day we encounter messages about weight and dieting and by implication the undesirability of fat. So, fat activists some years ago began to talk about and write about “coming out” —

“Unlike the gay body, the fat body is always already out. The fat body is of course hypervisible in terms of its mass in relation to the thinner bodies that surround it. As Moon suggests, the fat body displays ‘‘a stigma that could never be hidden because it simply is the stigma of visibility’’, and asks the question ‘‘What kind of secret can the body of the fat woman keep?’” — Samantha Murray

To come out as fat means to own it without apology or defense. It means owning my body as my own. It means surrendering the idea that the “real” me is thin and one day I will find the right diet or pill or potion that will release me and make me that “real” me. It means confronting inside myself the internalized fatism and stop hating my body. It means resting quietly within myself. 

Coming out as fat is not the same as coming out in the LGBT world. Because fat is visible and it is no secret to anyone who sees me that I am fat. In the case of fat, it is not a statement to the world, to my world, so much as a statement to myself, reflecting acceptance in myself of my body. 

But as a fat woman, in order to be good, I have to feel bad. In order to feel good, I have to be bad.

If I want to be perceived as good, I, and fat people in general, must present myself as the Good Fatty, the fat person who accepts the socially dominant viewpoint that my number one goal in life is losing weight. All I have to do is talk about trying to lose weight, about my desire to be thin. I can say I have lost 10 or 15 or 30 pounds and I will be praised for my efforts, even if it is a lie. The Good Fatty is apologetic for being fat and is in a perpetual state of trying to become thin. The Good Fatty doesn’t’t threaten thin people because she tells them she is engaged in the same struggle to subdue her body that they are. The Good Fatty is apologetic for her fat, as if she must ask forgiveness for committing an aesthetic crime with her too-muchness or must do penance for taking up too much space. She doesn’t complain that very few stores carry clothing in her size. She accepts as just that she pays more for her clothing, health care, and seats on airplanes. Because she knows she deserves it. She accepts without protest the “helpful” advice and criticism she receives from others because she is trying to become better, to become thin. She swallows her anger because she knows it is all her fault, that she has failed, and is getting what she deserves. She manages her fat identity by covering, by accepting that she should not be fat. She tries to cover her failure by always being in the process of trying to change, a perpetual state of atonement for the sin of being too big and too much.  She can be good so long as she feels bad.

But suppose I want to feel good, not bad. What then? Suppose I call myself fat. Not curvy. Not Rubenesque. Not zaftig or plump. Fat. I call myself fat. Just by calling myself fat, using that word unselfconsciously and without shame or apology, is to move away from being the Good Fatty. Just by calling myself fat, I break a taboo.

But what else? Embracing myself as I am. Coming out as myself, a fat woman who is simply who she is, what she is.

I made the decision over 40 years ago to stop dieting, I never talked about it with friends. I wasn’t dieting but I wasn’t willing to be public with having stepped out of being good, of forever being on the way to being thin. Being the Good Fatty is acting as if I embrace body hatred, dieting, guilt and shame so that I can at least be on the fringes of membership in the “normal” world. I can be good only by feeling bad. By feeling bad I can in a way be normal, be like other women. So stopping dieting is not coming out. It is an act of rebellion, to be sure, but the rebel is always defined by that against which she rebels. 

Coming out means being willing to be bad. It means letting go of the fantasy that there is a thin person inside waiting to get out and that she, not this fat me, is the real one. Coming out is to stop pretending to be trying to lose weight when I am not. Coming out means stopping defending how I eat or my health. Coming out is letting go of shame and embracing the body I have. Coming out is accepting myself, all of myself, fat and all. I can’t be good, be the way I am expected to be and do all of these things.

Perhaps the hardest thing, the most difficult part of coming out as fat, of leaving being good behind, is to really inhabit my fat body. Unconditionally. To love myself, my body exactly as it is, and not withhold that until I lose the 50 or 100 or however many pounds stand between me and being “normal”. No more apologies. No more mute acceptance of dieting advice. No more feeling bad because I take up space. That is the path to feeling good. It leads through a mountain of unexpressed rage and anger at having tried so hard for so long to be good, at having felt guilty and ashamed and bad for being too much. 

Therapy with a therapist who does not equate health with weight can be invaluable in the journey away from self-hatred to self-acceptance and love. 

Group News

Dream Group coming soon! For details, checkout Dream Group under –> Groups.

Please Tell Me What To Do

Often people say they left therapy because “the therapist wasn’t helping” with an expectation that the therapist should DO something — assign homework, give an exercise, something that feels like “doing”.

Now if I go to the dentist because I have pain in my mouth and the dentist doesn’t help, leaving to seek help elsewhere seems reasonable. But I look to the dentist to *do* something to make me feel better. The dentist does not usually, at least in acute situations, require of me that I do more than be cooperative and hold my mouth open. But psychotherapy is a different thing altogether. Therapists do not perform procedures upon patients in order to relieve their suffering. We might sometimes wish we could and certainly patients wish we would, but it just isn’t that way.

In any depth psychotherapy, the therapist does not tell the patient how to solve problems. The focus of treatment is exploration of the patient’s psyche and habitual thought patterns. The goal of treatment is increased understanding of the sources of inner conflicts and emotional problems. This understanding is what we call insight. Now insight without action is pretty useless. But the therapist doesn’t say to do this or that but instead might ask how this new understanding might be put into action in the patient’s life.

In order to accomplish this work of therapy, the patient and therapist must have a good working relationship, or therapeutic alliance. The patient needs to feel that the therapist is on her side, so to speak, allied with her in her desire to have a better, happier life. And in turn, the therapist needs from the patient a willingness to do the work of therapy, to put feelings into words, to talk about what she is thinking and feeling. And that includes being willing to talk about feelings of anger, disappointment or frustration about the therapy or therapist.

Most often when I hear people saying that therapy isn’t helping, I am also hearing an expectation that the therapist will tell the person what to do in order to feel better. And  to a very limited degree, we can do some of that — like take a walk or write in a journal or try painting or some other creative outlet when having difficulty between sessions. But on the big things — like whether or not to stay in a marriage or change careers or leave home or any of many many other important life decisions, we cannot tell a patient what to do. We, as human beings ourselves, have enough trouble finding our way through the complexities of our own lives and not only cannot, but really should not presume to be in a position to make decisions for others in their lives. No matter how much the patient may want it. But talking about wanting that, being angry that therapist won’t do it — that is the stuff of therapy. Because it is the relationship with the therapist that facilitates change.

Ultimately we behave with the therapist the way we do with most important people in our lives, with the same kinds of assumptions about the therapist and about ourselves. And we do so unquestioningly. 

It is also true that it is difficult for the therapist to respond to feelings and issues that the patient does not talk about. All rumors to the contrary, we are not mind readers! This underlies the basic therapeutic dictum that the patient should say whatever comes to mind.

Now of course, this is difficult for most of us, conditioned as we are by social norms, by rules we have learned from our parents. Remember Thumper in Bambi:”If you can’t say something nice, don’t say anything at all”? Most of us operate on some version of that in our relationships and avoid saying things to another person that we think might make them uncomfortable or angry with us. But therapy is a place where Thumper’s Rule needs to be suspended. So, if you don’t tell the therapist you don’t feel cared about, there isn’t much the therapist can do to help you with that. Similarly if you are angry with the therapist, have sexual feelings toward him or her, or any of the myriad of other feelings and thoughts about the therapist you might have. It all belongs in therapy. Putting those feelings into words is a key  part of what therapy is about, after all, because that opens the doorway to understanding where they come from and how to deal with them in ways that are helpful rather than destructive in life.

For psychotherapy to be effective a close rapport is needed, so close that the doctor cannot shut his eyes to the heights and depths of human suffering. The rapport consists, after all, in a constant comparison and mutual comprehension, in the dialectical confrontation of two opposing psychic realities. If for some reason these mutual impressions do not impinge on each other, the psychotherapeutic process remains ineffective, and no change is produced. Unless both doctor and patient become a problem to each other, no solution is found. C.G.Jung 

Now is a good time…

As more of us are becoming vaccinated and we begin to believe that the end of this very difficult time is in sight, oddly many of us are experiencing mildly-moderately distressing effects from having our lives constrained for the past year. Yesterday I read this very thoughtful article in the Atlantic:

Late-Stage Pandemic Is Messing With Your Brain

We have been doing this so long, we’re forgetting how to be normal.

One provocative thought:

“We’re trapped in our dollhouses,” said Kowert, the psychologist from Ottawa, who studies video games. “It’s just about surviving, not thriving. No one is working at their highest capacity.”

I haven’t driven more than a few miles this whole confined year. And though, as an introvert I haven’t found being just with myself and my husband unbearable, even I am chafing at the pace of return to whatever will be normal.

If you are finding this time difficult, that the forgetting that seems to come with living through this pandemic and its attendant confinement, now is a good time to consider therapy. To have a place  and time to talk about what has happened with your life this past year, about your fears, about the discoveries you have made about yourself.

I have openings. Contact me using the contact form on the Home page. I’d be delighted to hear from you.

Fat Patient, Thin Therapist

It is usually assumed that in a room with a slender therapist and a fat patient, it is the patient who has a weight problem. That therapist, benefitting from thin privilege may well assume that the way she eats, what she eats and how she exercises are what make her different from her patient, what make her thin and her patient fat. She may believe that because she carefully monitors what she eats and faithfully exercises, that she has control over her body, control that the fat woman could have if only she tried harder and did as she does. There is nothing in the media or even the professional literature to contradict her assumptions.

There are powerful transference/countertransference forces operating in therapy when fat enters the picture. As a fat patient I came to work with slender analysts with a full set of baggage and expectations based solely on my fears and projections about how my fat body would be experienced and regarded. Nothing in my experience with others contradicted these fears. And more often than not, my fears were borne out as valid. The language used to describe obesity – words like “grotesque”, “gargantuan”, “repulsive” – betray much about feelings toward fat people. It is important for the slender therapist to look within about her own attitudes and responses to fat.

A fat patient who wants to talk about weight exclusively, as if it were all that matters in life, is as much avoidant as is the fat patient who ignores weight entirely. And in either case, the therapist needs to be aware of how her own biases and/or discomfort play a role in this. There are very fine lines here. Weight and appearance and being outside the established norms are touchy things. It is difficult to become accepting of one’s own deviant(in the sense of differing from whatever is considered ‘normal’) body, to be at home with being different. The ambivalence is massive. The longing to fit in is right there next to defiance and anger about not being accepted. The therapist needs to walk that line without falling to either side, either by urging and cajoling weight loss or by denying the difficulties of being different from the expected norm. These are tricky waters for a therapist with thin privilege to try to navigate.

Just as we now know white analysts need to learn about African American culture, our fictional slender analyst needs to learn about the life her fat patient leads, about fat experience, about the experience of being reviled, judged, shunned, pathologized on a daily basis. And consider what her own unresolved body issues might be, because as Barbara Miller writes:

the experience of the analyst may…have to do with his or her own neurotic blind spots. And the analyst needs to consider such a possibility. Concerning neurosis Jung writes, ‘Behind a neurosis there is often concealed all the natural and necessary suffering the patient has been unwilling to bear’… And we can say that the analyst’s own not suffered pain can all too easily be disowned and then ‘found’ as the pain of the analysand: the neurotic countertransference. 

A female therapist, regardless of her weight, has had to deal with the expectations that women should be slender and attractive. Most likely she has dieted or thought about  dieting, fretted about any fluctuation in her weight, and experienced some anxiety about whether or not she is pretty enough, slender enough to attract a partner. In this sense she and her fat patient have shared experience, but her patient’s anxiety and fretting have not resulted in the slender body that the therapist has. And this can well become a source for a blind spot in the therapist – if she has been able through diet and exercise to be thin, then why wouldn’t that also be the answer for her fat patient?

That slender therapist needs to consider where her ideas about fat and fat people come from, what supports those ideas. The one article in Quadrant, a Jungian journal, in which obesity is even addressed carries bias right in the keywords given for the article: obesity, gorging, overeating, gluttony, hunger. 

Outside of the realm of fat studies, the Health At Every Size movement, and fat acceptance circles, the fat person is not seen as trustworthy or reliable about her own lived experience because it is assumed she is always defensive and denying the reality of her condition. If she says she eats moderately, often it will be asserted that she is in denial about how much she actually eats or some comment will be made about the unreliability of self-report. The fat woman is simply not trustworthy. 

Wilfred Bion’s dictum is to approach each session without memory or desire. If the therapist has in mind that her fat patient needs to lose weight in order to heal, whatever that means, then she is in fact imposing her agenda without determining if that is what the patient wants or needs. When the therapist holds this desire for her patient to change in particular ways, when she asserts her own agenda for the patient, Barbara Stevens Sullivan suggests that desire “reflects a yearning to be helped. “If I can put all the woundedness I sense in the room into the patient, and if I can fix it in him, I will be fixed, too”

The assumption, for both therapist and patient, most often is that if the patient loses weight and becomes slender, she will become more the person she is meant to be, that she will be healthier and happier. For any fat woman, her fat identity will remain no matter her weight — her memories of being fat, of her longings and pain alongside secret delight in her big body — are part of the fabric of her being and need to be heard, witnessed, and accepted. For the thin therapist this may mean receiving anger toward her as a representative of thin privilege, as one of the oppressors her fat patient has lived with. I think of my own rage when my first analyst blithely suggested I could lose a few pounds no matter my goals. A paradox for the therapist of a fat patient is that as Sullivan says,  “the analyst must let go of desire, even the desire to help, at the same time as she remains involved and concerned, desiring the best for her patient” and, I would add, accept that the best for her patient may not be what she herself would want or choose.

Even Good Guys…

This week there was a thread on Twitter about Irvin Yalom and how kind he is. I have read many of his books and have no doubt that in general he is indeed a kind person. 

I have been thinking and writing about the essay, “Fat Lady” in Irvin Yalom’s book, Love’s Executioner, which I read soon after it was published in 1989, for years. I was horrified by what he wrote:

The day Betty entered my office, the instant I saw her steering her ponderous two-hundred-fifty-pound, five-foot-two-inch frame toward my trim, high-tech office chair, I knew that a great trial of countertransference was in store for me.  

I have always been repelled by fat women. I find them disgusting: their absurd sidewise waddle, their absence of body contour‚ breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh. And I hate their clothes‚ the shapeless, baggy dresses or, worse, the stiff elephantine blue jeans with the barrel thighs. How dare they impose that body on the rest of us? (Yalom, 1989, pp. 94-95)

Yalom has been much praised for openly admitting such strong prejudice, such clear negative countertransference. And indeed it takes some courage to openly admit such feelings.  But in most of what I have read about that essay, no one questions that his revulsion in fact dominates the entire therapy. Nor are questions raised that he could think and feel this: “How dare they impose that body on the rest of us?” as if any of his patients owe it to him to be pleasing to his eye. Then again, it is acceptable to hate fat and to think ill of fat people so there was little chance of serious criticism except from the fat acceptance community whose opinions could be dismissed as defensive. Nevertheless, he does deserve credit for daring to say what no doubt many therapists think. But it is not enough to do that nor to feel bad about having done so. To fully understand how bad this kind of countertransference is, change “fat” to “Black” or “African American” — there would be a huge outcry over expression of such prejudice, even when admitted. But Betty was fat so many people felt and feel the way Yalom did.

In the course of the treatment described in Yalom’s essay, Betty loses 100 pounds. Of course, because weight is seen as the cause of her depression, because she loses so much weight, the therapy is deemed spectacularly successful.  Another story is revealed in the end of the essay when Yalom says:

“It’s the same with me, Betty. I’ll miss our meetings. But I’m changed as a result of knowing you .”  

She had been crying, her eyes downcast, but at my words she stopped sobbing and looked toward me, expectantly.  

“And, even though we won’t meet again, I’ll still retain that change.”  

“What change?”  

“Well, as I mentioned to you, I hadn’t had much professional experience with the problem of obesity.” I noted Betty’s eyes drop with disappointment and silently berated myself for being so impersonal.  

“Well, what I mean is that I hadn’t worked before with heavy patients, and I’ve gotten a new appreciation for the problems of… “ I could see from her expression that she was sinking even deeper into disappointment. “What I mean is that my attitude about obesity has changed a lot. When we started I personally didn’t feel comfortable with obese people.” 

In unusually feisty terms, Betty interrupted me. “Ho! ho! ho! Didn’t feel comfortable. That’s putting it mildly. Do you know that for the first six months you hardly ever looked at me? And in a whole year and a half you’ve never, not once, touched me? Not even for a handshake!”  

My heart sank. My God, she’s right! I have never touched her. I simply hadn’t realized it. And I guess I didn’t look at her very often either. I hadn’t expected her to notice!” (Yalom, 1989, p. 123)

Yalom was naïve to think that his distaste for Betty’s body had not been evident to her. She lived in a world that reviled her body and likely she, like many fat people, expected to encounter judgement. A more interesting question is why, given that she knew all along of his distaste, did she continue to work with him? The answer? She herself carries and directs those same feelings of disgust at herself.

We don’t know how Betty is now, more than thirty years later. Statistically she most likely has regained all of the weight lost and probably gained more. That is what happens when we try to tame the body through dieting. She may have had bariatric surgery and be among the minority who have not experienced complications from the surgery. Or perhaps she is in that tiny minority who succeeded in maintaining that weight loss. But in the years since the essay was published, no one questioned what losing weight was about for her and how working with a therapist filled with contempt and disgust for her body effected her feelings about herself. About what happens in a patient if even the therapist finds one’s body repulsive, even if the repulsion is not expressed.

It is all but impossible for a fat person, no matter the reasons for being fat, not to have a host of emotional issues about her size and her body. Every day the culture is telling her that she is too big, too much, not acceptable. Finding the courage to talk about those feelings in the presence of someone who finds her as disgusting as she herself often does is quite a feat. How does she find her voice about her anger at what she encounters? How is she to lovingly care about her body and for herself  if her therapist sees her body with the contempt and hatred she so often feels? And what if she is tired of having to devote herself to losing all that weight? The operative assumption is that in a room with a normal weight therapist and a fat patient, it is the patient who has a weight problem. What is it at work that makes it so difficult for the fat patient to be perceived as a whole person who might not share much less welcome the therapist’s agenda about her weight?